Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, March 07, 2008

Man and Machine

I don't keep up regularly with what's going on in my former clinic. Since just before I was leaving, they've been making the transition to fully electronic medical records. At the time, my experience with it was nothing but positive. It seems, however, that the process has come to a stage at which I'd have been driven crazy; were I still there but on the fence, it might have been the final straw.

I had lunch recently with some old friends; mainly nurses from our surgery center and a couple of nurse anesthetists, on the occasion of both of the latter recovering from recent surgery. Somehow my corner of the conversation came around to the software recently installed for inputing patient information, and the fact that it's not exactly user-friendly, especially for surgeons. A scenario was described that was like fingernails on a chalkboard.

The subject of electronic medical records has been frequently discussed in the medblogosphere; I think it's fair to say the majority opinion is that, from the point of view of doctors trying to record patient encounters, it sucks. And yet I've frequently commented that I generally thought the good far outweighed the bad. I may have spoken too soon, or, at least, based on a non-representative experience. In its first iteration, the institution of electronic medical records didn't change the way I did business. At that time, I was still able to dictate all my encounters and they were nearly immediately transcribed into the digital record. The only change was that I could get Xray images, consult notes, lab, instantly, from anywhere, without having to screw with finding the frequently-missing folders. But now, with the new format, as others have written, the doctors need to key information into a pretty rigid and unforgiving format, and it's gumming up the works. In terms of what's been described by other bloggers, that's old news. But it gets worse.

The program is so unwieldy, my anesthesia buddy told me, that it's slowing down the OR schedule. Surgeons need way more time to complete operative reports; the OR personnel wait in frustration until it gets done. Lateness, as I've written, burns a hole in my gut. But it gets worse still: because of the way the program is tied to current patient encounters, exacerbated by what sound like draconian penalties for lateness established by my former board (I was on it, once, and quit in frustration), it sounds as if that desirable human touch I was touting recently is getting squeezed into mechanized oblivion. The pressure to attend immediately to the record has gone amok.

In each exam room, I was told, there are now computer modules with sexy flat screens. Taking the history, docs cleave to the keyboard, asking questions while typing away, noses down. Some, I'd hope, might look up once in a while, but patients, they said, are complaining; and well they should. It sounds awful: impersonal, off-putting, humiliating, barrier-building. Some docs are refusing to do it this way, doing their typing back in their office after the visit. But doing so slows the schedule.

I remain convinced that the concept of electronic medical records is a good one: in any case, I'm certain the access issue is so important that there's no going back. Still, it seems there's a long way to go before finding a way to do it that enhances -- or at least doesn't detract from -- doctors' ability to use it efficiently. And willingly! Maybe voice-recognition technology will eventually advance to the point of being able instantly to digitize the sort of rapid-fire dictation that works so well when done immediately after the exam or operation. (I recall hearing old-days stories of surgeons at some big institution or another, dictating the op report from the prior operation to a stenographer while scrubbing for the next one!)

Every time I see my old cohorts I have a tinge -- a surge, really -- of regret that I burned out and bailed when I did. There's much I miss, and I think -- had there been a way to dial it back a bit -- I had more to offer. But on this occasion at least, I found myself thinking there's no way I'd have been happy with the current state of electronic affairs, and would likely either be screaming bloody murder, or producing another of my passive-aggresive (but brilliant) memos.

11 comments:

I work for Freakin Huge HMO, currently as a medical editor and transcriptionist. I"m also a patient at FHH, and was a sonographer there for 3 years - - so I've seen all sides of the EMR.

As a patient, I've watched my PCP try to make eye contact while she enters her office visit notes into the flatscreen. It's pretty stupid and intrusive.

So you mention better voice-recognition software than we have. Wel-l-l-l, see, machines aren't gonna get that right any time soon. Machines aren't me, for example - - - when a physician recently dictated an acoustic neuroma as 3 x 10 CM, not mm, I called him and said, "are you sure...?" When another physician dictated fetal renal pelves as 4 cm, not 4 mm, I called him too. And then there's the whole ilium - ileum thing, and many other word pairs of that ilk. When radiologists say "hyperdense" instead of "hyperechoic," I pick that up too, because I'm a sonographer. So....

I've read reports "written" with the "help" of Dragon Naturally Speaking, the bane (or one of them) at FHH, and to say they are gibberish is flattering. What they are is dangerous.

We have a problem, and globally, that problem is moving away from humans and moving toward mechanization. It's not good for medical professionals and it's not good for the patients.

I would love to wait outside an OR to slam out an operative report. I could do it almost as fast as he/she dictated it. What's so wrong with that?

Overall we are, not to put too fine a point on it, screwed. Hoist by our own petard, perhaps. We're on a slippery slope in medicine these days - but I don't have to tell you that.

What you describe is a typical case of IS running amok, trying to pigeon hole everything into the same neat little boxes - problem is the real world very rarely operates that way.

As you pointed out there is great value in being able to immediately access stored data information from a variety of sources, but there still needs to be the flexibility to input information in a way that is both efficient and suitable for the purpose at hand.

The folks that make & sell the software tout things like improved accuracy by eliminating errors in transcription, etc., and the bean counter types drool over this with visions of reduced staffing costs. The front end design is typically driven by some high paid consultant - unfortunately they rarely ask the front line operators (in this case the docs & nurses) what they really need. More often than not you wind up with a data input solution that is less efficient than what it replaced.

I don't have a problem with there being a PC in the exam room, in fact there are some great advantages that can be realized. The docs & nurses just need to recognize that it is just another tool at their disposal, know how to use it, and not let it drive the provider/patient interaction.

My HMO has an integrated system that really works well, but it has taken them years to get to that point.

EMRs are a great idea in theory, but so far what I have seen is amazingly shoddy programming and design. A software engineer friend of mine, who once saw the EMR in action, could not believe the code that was being pushed.

The particular EMR I work is particulary bad. If you enter data, and forget to immediately 'refresh' the record, no other person can see that data. I contacted my IT department about several obvious ways to improve the software, but have not gotten anywhere.

Given the propensity of doctors who hate typing out information, and prefer to write it (especially during a patient interview), I'm surprised there aren't a greater number of well-designed EMRs out there that make use of TabletPC technology.

I'm not saying handwriting recognition (because we all know how well that'd work), but at least digital ink, so that everyone can access the "written" file, just like we did back in the pen and paper days.

Only identifying information and key diagnostic/billing tags would need to be "typed" in some manner to avoid errors.

EMRs are just a symptom of the growing loss of physician autonomy. It's come to the point where insurers and hospitals have the ability to dictate anything, no matter how ridiculous, and you have no choice but to follow it or leave. And each little thing isn't worth leaving, but it builds up, over and over.

My favorite was when we were forced to sit and listen to some clueless person talk about how letting people say "I need clarification" was going to improve patient results. Over and over they said, no matter what you are doing if anyone says this you must IMMEDIATELY stop ANYTHING you are doing and "clarify" them.

Yes. No exceptions (this is specifically stated). Anything. I'm sorry Mrs. Smith, but your mother died because I was required to take some time off to provide some clarification on where I wanted the central line while she was coding. And there are countless examples like this, of where one more thing in your workday becomes frustrating and insulting, but... BOHICA (as they say in the military). It's all downhill from here with the increasing willingness of CMS to directly dictate every aspect of patient treatment.

Health care systems need people like you...so even if you aren't actively in the system, hopefully you will participate assertively in professional associations that can have an impact by establishing professional protocols. These computerized systems should rolled out slowly so that strategies can be developed to manage the newly created problems. Faster isn't always better...in some instances all we're doing is enabling people to make mistakes at a faster pace.Onehealthpro

I'm jumping in a little late in the game here, but at least my comments will be preserved here for future e-archaeologists to ponder.

My wife is just about to finish medical school (Match Day is next week!) and her institution has been using one of the EMR systems for her whole time there. In fact, the place seems to be rather advanced in computer terms. A number of the places we went for residency interviews are still essentially in the stone age using all paper records (including one esteemed school that starts with an "M" and ends with an "ichigan." The places that do have an EMR use different systems at different facilities. Her current school uses the same system at all hospitals and clinics throughout the region. I've gotten the impression from her that it is a crummy piece of junk, but the wide use lets staff learn it and become accustomed to working with it.

Of course, in their infinite wisdom, the higher ups only gave medical students read access on the system. Now that most departments are rid of paper, students cannot write notes on patients at all, much to the residents' chagrin.

As far as voice recognition goes, my wife told me about her experience in Radiology last week. The radiologists use a computer to read films and dictate notes. Of course, she says they are typing corrections the whole time they are dictating to the software. In one case, however, the residents found a workaround. My wife heard a resident dictating, "Connecticut shows a . . .," and repeating the state name over and over. She asked what he was doing. The resident was not planning a vacation to the northeast. He said, "When we say 'CT' the computer puts 'CD'. If we say 'Connecticut,' it spits out 'CT'."

I have been exposed to a number of EMR's and have found most of them lacking. Surpringly, one that is often touted as doing it's job fairly well is the old VA system. I'm not sure how it stands up now, but even as of 8 years ago, it was considered decent.

The benefits of a widespread EMR are amazing. I loved being able to look up my patients medical records the day before seeing them. That was much better than being surprised when a "skin bump" on your schedule turned out to be a known sarcoma! I thought it was great being able to read your consultants notes and films online. How often have patients come to your office with no idea why they're there, or without labs/studies/path that you really needed to help them? Even the downsides of typing weren't that bad, at least your office chart never got lost.

I think as our physician population evolves, and a more computer savvy generation starts to take hold, some of these complaints will be a little less important.

But, as somebody earlier stated, whoever finds a good solution to this problem will become a very very rich man.

Hey Sid,I work for a company called Practice Fusion, and I’d like to clear up a few things about EMRs. There is a lot of skepticism surrounding the security and quality of EMR software, especially when it is free and web-based. I would like to start off by saying that there are costly applications out there (like Mysis)that want you to believe you must pay for quality. But realistically, there are many high-quality, web-based applications out there. Google Apps. is just one example. I can honestly say that we deliver the best product and support at absolutely no cost, and with no on-site implementation. And that is why we are one of the fastest growing physician practice communities in the United States. We have outstanding technical support, and we pride ourselves on our ‘Live in Five' process which allows us to get users started within five minutes of calling. If you are interested in learning more about Practice Fusion, you can check out our free EMR. Also, take a look at what others have to say about us: http://www.fiercehealthit.com/innovators/2007/practicefusion, http://blogs.zdnet.com/BTL/?p=4670, http://blogs.zdnet.com/Stewart/?p=774. If you prefer, we invite you all to visit website and take a demo with a Practice Fusion team member – Simply call us at 415-346-7700.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.